Endovascular therapy alone be considered first-line in this setting, study authors advise.
Patients who are anticoagulated at the time they experience an acute ischemic stroke can undergo mechanical thrombectomy, with similar safety and efficacy outcomes as non-anticoagulated patients, according Spanish registry data published online last month in the Journal of NeuroInterventional Surgery.
Randomized trials have shown that “combining endovascular mechanical thrombectomy with intravenous recombinant tissue plasminogen activator (rtPA) is clinically more beneficial than intravenous rtPA alone in patients with acute ischemic stroke and occlusion of a large intracerebral artery in the anterior circulation,” Gustavo Zapata-Wainberg, MD (Hospital Universitario de la Princesa, Madrid, Spain), and his co-investigators note. At the same time, however, there are scant data on the safety and efficacy of endovascular treatment among patients who are already anticoagulated, and in whom IV tPA is therefore contraindicated.
Zapata-Wainberg and colleagues conducted a retrospective multicenter study of 502 patients with acute ischemic stroke treated with mechanical thrombectomy using data from the Madrid Stroke Network. Of these patients, 20.7% were taking vitamin K antagonists (VKAs) at the time of the stroke, 9 1.8% were taking direct oral anticoagulants (DOACs), and 77.5% were not anticoagulated. IV thrombolysis was performed in 59.8% of the non-anticoagulated and 15.0% of the anticoagulated patients.
There were no differences between patients who were and were not anticoagulated at the time of their stroke with respect to rates of intracranial hemorrhage, recanalization, 3-month functional outcomes, or mortality.
Outcomes Based on Anticoagulation at Time of Stroke
|
|
Without (n = 389) |
With (n = 113) |
P Value |
|
Intracranial Hemorrhage |
27.5% |
20.4% |
NS |
|
TICI Score > 2a |
82.3% |
82.3% |
NS |
|
3-Month mRS ≤ 2 |
56.3% |
55.7% |
NS |
|
Mortality |
13.1% |
12.4% |
NS |
In addition, there were no differences seen between patients anticoagulated with VKAs versus DOACs with regard to rates of intracranial bleeding, mRS score, or mortality.
“Our study showed that mechanical thrombectomy was feasible in anticoagulated patients with acute ischemic stroke,” conclude the authors. “This is very relevant, since effective anticoagulation is a contraindication for intravenous thrombolysis and only mechanical thrombectomy can be performed in this setting. In this context, endovascular therapy alone may be considered as first-line therapy, regardless of anticoagulation use.”
Additional research, they say, is “warranted to clarify whether DOACs provide added value in this setting compared with VKAs.”
Source:
Zapata-Wainberg G, Ximénez-Carrillo Á, Trillo S, et al. Mechanical thrombectomy in orally anticoagulated patients with acute ischemic stroke. J NeuroInterv Surg. 2017;Epub ahead of print.
Disclosure:
Zapata-Wainberg reports no relevant conflicts of interest.
